Machine learning prediction of pathological complete response and overall survival of breast cancer patients in an underserved inner-city population

BACKGROUND

Generalizability of predictive models for pathological complete response (pCR) and overall survival (OS) in breast cancer patients requires diverse datasets. This study employed four machine learning models to predict pCR and OS up to 7.5 years using data from a diverse and underserved inner-city population.

METHODS

Demographics, staging, tumor subtypes, income, insurance status, and data from radiology reports were obtained from 475 breast cancer patients on neoadjuvant chemotherapy in an inner-city health system (01/01/2012 to 12/31/2021). Logistic regression, Neural Network, Random Forest, and Gradient Boosted Regression models were used to predict outcomes (pCR and OS) with fivefold cross validation.

RESULTS

pCR was not associated with age, race, ethnicity, tumor staging, Nottingham grade, income, and insurance status (p > 0.05). ER-/HER2+ showed the highest pCR rate, followed by triple negative, ER+/HER2+, and ER+/HER2- (all p < 0.05), tumor size (p < 0.003) and background parenchymal enhancement (BPE) (p < 0.01). Machine learning models ranked ER+/HER2-, ER-/HER2+, tumor size, and BPE as top predictors of pCR (AUC = 0.74-0.76). OS was associated with race, pCR status, tumor subtype, and insurance status (p < 0.05), but not ethnicity and incomes (p > 0.05). Machine learning models ranked tumor stage, pCR, nodal stage, and triple-negative subtype as top predictors of OS (AUC = 0.83-0.85). When grouping race and ethnicity by tumor subtypes, neither OS nor pCR were different due to race and ethnicity for each tumor subtype (p > 0.05).

CONCLUSION

Tumor subtypes and imaging characteristics were top predictors of pCR in our inner-city population. Insurance status, race, tumor subtypes and pCR were associated with OS. Machine learning models accurately predicted pCR and OS.

Abstract GS1-05: Trial Assigning Individualized Options for Treatment (TAILORx): An Update Including 12-Year Event Rates

Background: Late recurrence of breast cancer after 5 years accounts for about 50% of recurrences in hormone receptor (HR)-positive early breast cancer (EBC). TAILORx established non-inferiority of adjuvant endocrine therapy (ET) given for at least 5 years to chemotherapy plus ET (CET) in EBC and a 21-gene recurrence score (RS) of 11-25, although there was some chemotherapy benefit in women

Methods: Eligibility criteria included women 18-75 years with HR-positive, HER2-negative, T1b-T2N0 EBC who agreed to have CT assigned or randomized based on the RS assay. The primary endpoint was invasive disease-free survival (iDFS) in the RS 11-25 group. The “primary analysis” refers to the original prespecified analysis for the primary IDFS endpoint (836 IDFS events at full information in the RS 11-25 group) after a median of 7.5 years. The “updated analysis” was performed after a median followup of 11.0 and 10.4 years in the randomized and overall populations, respectively.

Results:10,253 eligible women enrolled between 4/7/06-10/6/10.The updated analysis includes substantially more events that the primary analysis, including IDFS events (1819 vs. 1210), distant recurrences (561 vs. 384), locoregional +/- distant recurrences (764 vs. 543), and deaths (910 vs. 499). The table provides 5 and 12-year event rates (and standard errors) for all arms, and comparisons of the randomized arms. The primary trial conclusions remain unchanged: ET was non-inferior to CET in the randomized group with a RS 11-25. Although recurrence occurred in &lt; 10% by 12 years for a RS 0-25, late recurrence events beyond 5 years exceeded earlier recurrence. Non-recurrence events occurred in about 13% at 12 years (~1%/year), contributing substantially to the IDFS rates. For women

Conclusions: The current updated analysis confirms findings from the original primary analysis that ET is non-inferior to CET in HR-positive, HER2-negative, node-negative EBC and a RS 11-25. As in the original primary analysis, the subgroup of women

An interactive mobile application versus an educational booklet to promote job retention in women undergoing adjuvant chemotherapy for breast cancer: a randomized controlled trial

BACKGROUND

Job loss after a cancer diagnosis can lead to long-term financial toxicity and its attendant adverse clinical consequences, including decreased treatment adherence. Among women undergoing (neo)adjuvant chemotherapy for breast cancer, access to work accommodations (e.g., sick leave) is associated with higher job retention after treatment completion. However, low-income and/or minority women are less likely to have access to work accommodations and, therefore, are at higher risk of job loss. Given the time and transportation barriers that low-income working patients commonly face, it is crucial to develop an intervention that is convenient and easy to use.

METHODS

We designed an intervention to promote job retention during and after (neo)adjuvant chemotherapy for breast cancer by improving access to relevant accommodations. Talking to Employers And Medical staff about Work (TEAMWork) is an English/Spanish mobile application (app) that provides (1) suggestions for work accommodations tailored to specific job demands, (2) coaching/strategies for negotiating with an employer, (3) advice for symptom self-management, and (4) tools to improve communication with the medical oncology team. This study is a randomized controlled trial to evaluate the app as a job-retention tool compared to a control condition that provides the app content in an informational paper booklet. The primary outcome of the study is work status after treatment completion. Secondary outcomes include work status 1 and 2 years later, participant self-efficacy to ask an employer for accommodations, receipt of workplace accommodations during and following adjuvant therapy, patient self-efficacy to communicate with the oncology provider, self-reported symptom burden during and following adjuvant therapy, and cancer treatment adherence.

DISCUSSION

This study will assess the use of mobile technology to improve vulnerable breast cancer patients' ability to communicate with their employers and oncology providers, work during treatment and retain their jobs in the long term, thereby diminishing the potential consequences of job loss, including decreased treatment adherence, debt, and bankruptcy.

TRIAL REGISTRATION

ClincalTrials.gov NCT03572374 . Registered on 08 June 2018.

EZH2 Protein Expression in Estrogen Receptor Positive Invasive Breast Cancer Treated With Neoadjuvant Endocrine Therapy: An Exploratory Study of Association With Tumor Response

INTRODUCTION

Neoadjuvant endocrine therapy (NET) can be used to treat estrogen receptor positive (ER+) invasive breast cancer (IBC). Tumors with Ki67>10% after 2 to 4 weeks of NET are considered resistant to endocrine therapy. Enhancer of Zeste Homolog 2 (EZH2) is a targetable oncoprotein and overexpression in ER+ IBC has been linked to resistance to endocrine therapy. We examined whether EZH2 expression levels in ER+ IBC could be used to predict response to NET.

MATERIALS AND METHODS

We retrospectively identified 46 patients with localized ER+ HER2/neu negative IBC treated with a minimum of 4 weeks of NET. We quantified EZH2 nuclear expression in pretherapy core biopsies using a score that included intensity and percent of cells staining. Ki67 was evaluated in both pretherapy core biopsies and posttherapy tumor resections and scored according to the guidelines of the International Ki67 Working Groups, with a global weighted score. Ki67≤10% after NET was considered endocrine responsive. Logistic regression analysis was performed to determine the association between EZH2 expression and response to NET.

RESULTS

We found significant associations of tumor grade ( P =0.011), pretherapy Ki67 ( P =0.003), and EZH2 ( P <0.001), with response to NET. On logistic regression adjusted for tumor grade and pretherapy Ki67, increased EZH2 scores were associated with decreased odds of endocrine responsiveness, defined as posttreatment Ki67≤10% (odds ratio=0.976, 95% CI, 0.956 to 0.997; P =0.026). In addition, with EZH2 score in the model, associations of tumor grade and pretreatment Ki67 with posttreatment Ki67≤10% response to NET became not significant.

CONCLUSIONS

Our results suggest that EZH2 might be a useful biomarker to predict response to NET.

EZH2 Protein Expression in Triple-negative Breast Cancer Treated With Neoadjuvant Chemotherapy: An Exploratory Study of Association With Tumor Response and Prognosis

INTRODUCTION

Neaodjuvant chemotherapy is used to treat high risk triple-negative breast cancer (TNBC). Residual cancer burden (RCB) is used to predict risk of relapse after neoadjuvant chemotherapy (NAC); however, it cannot predict disease recurrence with certainty. EZH2 is a targetable oncogenic protein overexpressed in TNBC and associated with metastasis and stem cell expansion. We quantified EZH2 protein expression in TNBC before NAC to examine potential utility as a predictive and prognostic biomarker.

MATERIALS AND METHODS

We retrospectively identified 63 patients with localized TNBC treated with NAC. We quantified EZH2 nuclear expression in pretherapy biopsies using a score which included intensity and percent of positive cells at each intensity. EZH2 expression was evaluated as a continuous variable and dichotomized at a score of 210. Logistic regression analysis was used to determine association between EZH2 expression and RCB, tumor-infiltrating lymphocytes, clinicopathologic features and disease-free survival.

RESULTS

There was no significant association between EZH2 score and posttreatment RCB class evaluated as a continuous variable (P=0.831) or dichotomized at 210 (P=0.546). On multivariable logistic regression, adjusted for covariates including RCB, EZH2 >210 was associated with development of metastasis (odds ratio=14.35, 95% confidence interval: 2.69-76.66; P=0.002). Logistic regression was run with EZH2 scores as a continuous variable and increased EZH2 score was associated with metastasis (odds ratio=1.10, 95% confidence interval: 1.00-1.03; P=0.047).

CONCLUSION

In our study of TNBC treated with NAC, high EZH2 expression in pretherapy core biopsies was significantly associated with metastatic recurrence independent of RCB. The potential value of EZH2 as a biomarker to improve stratification of outcome after NAC should be explored further.

Abstract P1-17-12: Preliminary data from a phase I/II, multicenter, dose escalation study of OP-1250, an oral CERAN/SERD, in subjects with advanced and/or metastatic estrogen receptor (ER)-positive, HER2-negative breast cancer

Background: ER+, HER2- metastatic breast cancer (MBC) patients will receive sequential, endocrine based therapy, either as monotherapy or in combination with a targeted agent until endocrine resistance develops. OP-1250 is a small molecule Complete Estrogen Receptor Antagonist (CERAN) that completely inactivates ER by blocking the 2 activation functions of ER transcription (AF-1 & AF-2). While complete antagonism is believed to be the most critical mechanism of action, OP-1250 is also a strong degrader of the ER. OP-1250 demonstrates anti-cancer activity in preclinical models, including activity against brain metastases and in tumors with activating mutations in ESR1. OP-1250 is orally bioavailable with favorable pharmacokinetics (PK) yielding high and steady drug levels in multiple species. The characteristics of OP-1250 including PK, ability to cross the blood brain barrier, and complete antagonism of the ER suggest that OP-1250 may have superior efficacy over standard of care and experimental agents, both as a monotherapy and in combination with other targeted therapies. Methods: OP-1250-001 is a phase I/II first-in-human study to determine the Dose Limiting Toxicity (DLT), Maximum Tolerated Dose (MTD) and/or Recommended Phase II Dose (RP2D) and to characterize the safety, PK profile and preliminary efficacy in subjects with ER+, HER2- MBC. Eligible patients received prior endocrine therapy. OP-1250 was given orally, once a day continuously in 28-day cycles. Using a rolling 6 design, cohorts of 3 - 6 subjects were sequentially enrolled and monitored for DLTs. The study allows for expansion of 1 or 2 doses for further evaluation of safety and PK to best inform selection of the RP2D. The phase II portion will evaluate the preliminary activity of OP-1250 in 3 cohorts: 1) measurable disease; and 2 exploratory cohorts: 2) evaluable & non-measurable; and 3) central nervous system metastasis. Plasma is being collected for ctDNA sequencing to evaluate ESR1 and other relevant mutations. Results: Between August 5, 2020 and June 4, 2021, 28 subjects with a median age of 63 (range 37-82) have been enrolled. Of the 27 subjects for whom detailed data on prior therapy was reported, all subjects received &gt; 1 prior endocrine therapy for MBC (74% received &gt; 2 and 37% received &gt; 3; range 1-6). All of the 27 subjects received a CDK4/6 inhibitor and 23 of 27 (85%) had received fulvestrant. 20 subjects of 28 (71%) subjects had visceral disease affecting the liver, lung, peritoneum, and/or pleura. OP-1250 was escalated through 5 dose cohorts (range 30 - 300 mg qd). 26 patients were evaluable for a DLT. As of the data cut-off date, no DLTs occurred. Most of the TEAE were grade 1 or 2. OP-1250 is orally bioavailable and extensively distributed with an effective half-life of approximately 2-3 days. Cmax and AUC show dose proportional increase. By cycle 2, exposure levels are at steady state with limited fluctuations and at all doses significantly higher than those seen with fulvestrant. Importantly, OP-1250 has now demonstrated clinical activity at doses that were well tolerated and within the predicted exposure windows where maximum efficacy was observed in preclinical models. Detailed response and safety data will be presented. Conclusion: OP-1250 is continuing evaluation in a phase I/II study. The population enrolled reflects the evolving standard of care in that all pts received prior CDK4/6 inhibitors and the majority also received fulvestrant. OP-1250 is well tolerated with a favorable PK across dose levels ensuring target coverage throughout the dosing interval. No MTD has been identified and selection of the RP2D will be based on consideration of long-term tolerability, efficacy, and the ability to combine with targeted agents. (NCT04505826)

Citation Format: Manish Patel, Carlos Alemany, Zahi Mitri, Della Makower, Virginia Borges, Joseph Sparano, Trinh Le, Pamela Klein, Julia Lawrence, Peter Kushner, Demiana Faltaos, Cyrus Harmon, David Myles, JoAnne Zujewski, Erika Hamilton. Preliminary data from a phase I/II, multicenter, dose escalation study of OP-1250, an oral CERAN/SERD, in subjects with advanced and/or metastatic estrogen receptor (ER)-positive, HER2-negative breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-17-12.

The 21-gene recurrence score in early non-ductal breast cancer: a National Cancer Database analysis

The 21-gene recurrence score (RS) is prognostic for recurrence and predictive of chemotherapy benefit in early estrogen receptor-positive (ER +) HER2-negative (HER2-) breast cancer (BCA). We evaluated clinicopathologic characteristics, RS and chemotherapy benefit in invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), and carcinomas of mixed histologies (ductal + lobular (DLC), ductal + other (DOC), lobular + other (LOC)). Women diagnosed between 1/1/2010 and 1/1/2014 with ER + HER2- BCA, measuring <5 cm, with 0–3 involved axillary nodes, surgery as first treatment, and available RS, were identified from the NCDB. Associations between categorical variables were examined using chi-square test. Cox proportional hazards model was used to examine overall survival (OS) differences among histology subtypes. IDC was associated with smaller size, high grade, and RS > 26. ILC was associated with larger size, and least likely to be high grade (p < 0.0001). Lobular histology was associated with lower incidence of RS > 26. IDC patients (pts) were more likely to receive chemotherapy than pts with other histologies (p < 0.0001). OS for IDC, ILC and DOC were similar. DLC was associated with improved OS (HR 0.82, p = 0.02). Adjuvant chemotherapy was associated with improved OS in IDC (HR = 0.76, p < 0.0001) but not in ILC (HR = 0.99, p = 0.93), DLC (HR = 1.04, p = 0.86), DOC (HR = 0.87, p = 0.71), or LOC (HR = 2.91, p = 0.10). Lobular and mixed BCA histologies have distinct clinicopathologic features compared with IDC, and are less likely to have high RS. OS is similar for IDC and ILC. Although chemotherapy benefit was seen only in IDC, benefit for ILC with RS > 26 cannot be excluded.

Abstract P037: A phase 1/2 dose escalation and expansion study of OP-1250 in adults with advanced and/or metastatic hormone receptor-positive (HR+), HER2-negative (HER2−) breast cancer

Background: Endocrine therapy administered sequentially as monotherapy or in combination with targeted therapy is the primary treatment for HR+, and HER2- metastatic breast cancer (MBC). Most patients with HR+, HER2- MBC will develop resistance to available therapies. More effective therapies are needed for HR+, HER2- MBC and for the treatment of endocrine therapy-resistant disease. OP-1250 is a small molecule Complete Estrogen Receptor ANtagonist (CERAN) that completely inactivates ER, blocking the activity of both the AF1 and AF2 transcriptional activation functions, inhibits ER-driven breast cancer cell growth, and induces ER degradation. OP-1250 demonstrates anti-cancer activity in vitro and in vivo, including activity against mouse models of metastases in the brain and tumors with activating mutations in ESR1. OP-1250 is orally bioavailable with a favorable pharmacokinetic (PK) profile enabling once-daily dosing. OP-1250’s complete ER antagonism is hypothesized to result in superior efficacy compared to agents that only partially antagonize and/or degrade but do not completely antagonize ER. Trial design: Goals of this phase 1/2 are to determine the Dose Limiting Toxicity (DLT), Maximum Tolerated Dose (MTD) and/or Recommended Phase 2 Dose (RP2D), to characterize the safety and PK profile, and to determine the preliminary activity of OP-1250 in subjects with HR+, HER2- MBC. Ph 1 (Dose Escalation) will evaluate escalating doses of orally administered OP-1250 to determine the safety, pharmacology, MTD (if any) and/or the RP2D. Cohorts of 3 to 6 subjects will be sequentially enrolled and monitored for DLTs during cycle 1. Eligibility criteria include males, and both pre- and post-menopausal females, age 18 or older, with ER+, HER2- advanced or MBC (pre-menopausal women must be on an LHRH antagonist); prior CDK4/6 and SERD and fulvestrant are permitted; ECOG of 0 or 1. The objectives of the phase 1 are: identification of the DLT, MTD and/or RP2D and assessment of the safety and tolerability and PK of OP-1250. Objectives of the phase 2 are to assess the objective response rate (ORR) of OP-1250 in 1) subjects with HR+, HER2- MBC who have progressed on endocrine therapy and have no evidence of central nervous system (CNS) metastases, 2) in patients with non-measurable disease, and 3) in patients with CNS disease. Correlative analyses include ER, PR, Ki67 in tumor biopsies and ctDNA pre- and post-therapy for activating mutations in ESR1. Summary: OP-1250, a complete estrogen receptor antagonist (CERAN), is currently being evaluated in a phase 1/2 study in ER+, HER2- MBC. For more information, please contact clinical@olema.com (NCT04505826)

Citation Format: Carlos Alemany, Manish Patel, Zahi Mitri, Joseph Sparano, Virginia Borges, Della Makower, Pam Klein, Julia Lawrence, Trinh Le, Jo Anne Zujewski, Erika Harmilton. A phase 1/2 dose escalation and expansion study of OP-1250 in adults with advanced and/or metastatic hormone receptor-positive (HR+), HER2-negative (HER2−) breast cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P037.

The clinical utility of gene expression assays in breast cancer patients with 0-3 involved lymph nodes

Multigene expression assays are prognostic for recurrence in hormone-receptor positive 2 (HER-2) negative breast cancer, and, in some cases, predictive of benefit from chemotherapy or extended endocrine therapy. The results of these assays may be used to guide treatment recommendations for early HER-2 negative breast cancer. We review the results of trials establishing the clinical utility of several commercially available gene expression assays.

Seroconversion rates following COVID-19 vaccination among patients with cancer

As COVID-19 adversely affects patients with cancer, prophylactic strategies are critically needed. Using a validated antibody assay against SARS-CoV-2 spike protein, we determined a high seroconversion rate (94%) in 200 patients with cancer in New York City that had received full dosing with one of the FDA-approved COVID-19 vaccines. On comparison with solid tumors (98%), a significantly lower rate of seroconversion was observed in patients with hematologic malignancies (85%), particularly recipients following highly immunosuppressive therapies such as anti-CD20 therapies (70%) and stem cell transplantation (73%). Patients receiving immune checkpoint inhibitor therapy (97%) or hormonal therapies (100%) demonstrated high seroconversion post vaccination. Patients with prior COVID-19 infection demonstrated higher anti-spike IgG titers post vaccination. Relatively lower IgG titers were observed following vaccination with the adenoviral than with mRNA-based vaccines. These data demonstrate generally high immunogenicity of COVID-19 vaccination in oncology patients and identify immunosuppressed cohorts that need novel vaccination or passive immunization strategies.

Lymphovascular invasion, race, and the 21-gene recurrence score in early estrogen receptor-positive breast cancer

Lymphovascular invasion (LVI) and Black race are associated with poorer prognosis in early breast cancer (EBC). We evaluated the association between LVI and race, and whether LVI adds prognostic benefit to the 21-gene recurrence score (RS) in EBC. Women with ER+ HER2- EBC measuring up to 5 cm, with 0-3 involved axillary nodes, diagnosed between 1 January 2010 and 1 January 2014, who underwent surgery as first treatment and had available RS, were identified in the NCDB database. Bivariate associations between two categorical variables were examined using chi-square test. Multivariate Cox proportional hazards model were used to assess the association of LVI, race, and other covariates with overall survival (OS). 77,425 women, 65,018 node-negative (N0), and 12,407 with 1-3 positive (N+) nodes, were included. LVI was present in 12.7%, and associated with poor grade, RS 26-100, and N+ (all p < 0.0001), but not Black race. In multivariate analysis, LVI was associated with worse OS in N0 [HR 1.37 (95% CI 1.27, 1.57], but not N+ EBC. LVI was associated with worse OS in N0 patients with RS 11-25 [HR 1.31 (95% CI 1.09, 1.57)] and ≥26 [HR 1.58 (95% CI 1.30, 1.93)], but not RS 0-10. No interaction between LVI and chemotherapy benefit was seen. Black race was associated with worse OS in N0 (HR 1.21, p = 0.009) and N+ (HR 1.37, p = 0.015) disease. LVI adds prognostic information in ER+, HER2-, N0 BCA with RS 11-100, but does not predict chemotherapy benefit. Black race is associated with worse OS, but not LVI.

Abstract PS6-20: The 21-gene recurrence score in early non-ductal breast cancer: A national cancer database analysis

Background: The Oncotype DX 21-gene expression assay (ODX) is prognostic for recurrence and predictive of chemotherapy benefit in early estrogen receptor-positive (ER+) HER2-negative (HER2-) breast cancer (BCA). Invasive ductal carcinoma (IDC) comprises approximately 80% of BCA. Invasive lobular carcinoma (ILC) is a subtype of BCA with distinct pathologic features, and often has low to intermediate ODX Recurrence Score (RS). We evaluated differences in clinicopathologic characteristics, RS and chemotherapy benefit between IDC, ILC, and carcinomas of mixed histologies (ductal + lobular (DLC), ductal + other (DOC), and lobular + other (LOC)) in the National Cancer Database (NCDB). Methods: Female patients (pts) diagnosed between 1/1/2010 and 1/1/2014 with ER+ HER2- BCA, measuring up to 5 cm, with 0-3 involved axillary lymph nodes (LN), treated with definitive surgery as first treatment, and with numeric ODX recurrence score (RS) available were identified from the 2005-2016 NCDB database. Associations between categorical variables were examined using the chi-square test. The Cox proportional hazards model was used to examine the difference in overall survival between histology subtypes while controlling for age, race/ethnicity, RS, tumor size, grade, LN involvement and treatment. Results: 77,472 pts met inclusion criteria, 62,395 (83.8%) node negative (N0) and 12,077 (16.2%) node positive (N+). 57,615 pts (77.4%) had IDC; 8693 (11.7%) ILC; 5393 (7.2%) DLC; 2457 (3.3%) DOC; and 312 (0.4%) LOC. DOC and LOC were more common in Black than White pts (p&lt;0.0001). IDC was associated with smaller tumor size and high grade disease. ILC was associated with larger tumor size, and was least likely to be high grade (p&lt;0.0001). IDC was most likely to have high RS &gt;26. Presence of lobular histology (ILC, DLC and LOC) was associated with lower incidence of RS &gt;26. ILC was least likely to have both low RS (0-10) and high RS (p&lt;0.0001). Pts with IDC were more likely to receive adjuvant chemotherapy (27.4%) than pts with other BCA types (ILC 19.3%; DLC 21.9%; DOC 20.5%; LOC 19.2%, p&lt;0.0001). Overall survival (OS) for IDC, ILC and DOC were similar. DLC was associated with improved OS compared with IDC (HR 0.82, p=0.02). Receipt of adjuvant chemotherapy was associated with improved OS in IDC (HR=0.76, p&lt;0.0001) but not in ILC (HR=0.99, p=0.93), DLC (HR=1.04, p=0.86), DOC (HR=0.87, p=0.71), or LOC (HR=2.91, p=0.10). Conclusion: Lobular and mixed BCA histologies have distinct clinicopathologic features compared with IDC, and are less likely to have high RS. OS is similar for early IDC and ILC. Chemotherapy benefit was not seen in ILC or mixed BCA histologies.

Citation Format: Della Makower, Jiyue Qin, Juan Lin, Xiaonan Xue, Joseph A Sparano. The 21-gene recurrence score in early non-ductal breast cancer: A national cancer database analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-20.

Abstract P3-08-06: Lymphovascular invasion (LVI), the 21-gene recurrence score, and race in early estrogen receptor-positive, HER2-negative breast cancer: A national cancer database (NCDB) analysis

Background: LVI and black race are associated with poorer prognosis in early breast cancer (BCA). The Oncotype DX 21-gene Recurrence Score (RS) is both prognostic for recurrence and predictive of chemotherapy benefit in estrogen-receptor positive (ER+), HER2-negative (HER2-) early BCA. Black women enrolled on the TAILORx trial, which assigned or randomized women with hormone receptor-positive, HER2-, node-negative (N0) BCA to adjuvant therapy based on RS, had a 1.4-fold higher risk of recurrence than white women, despite similar RS distribution, treatment, and reported adherence to endocrine therapy. No prior studies have evaluated the impact of LVI, RS, and race in the same population, to assess whether LVI contributes to racial disparities or adds prognostic information to RS.

Methods: Female patients diagnosed between 1/1/2010 (the first year LVI was collected by NCDB) and 1/1/2014 with ER+ HER2- BCA, measuring up to 5 cm, with 0-3 involved axillary nodes, treated with definitive surgery as first treatment, and with numeric RS available, were identified from the 2005-2016 NCDB database. Bivariate associations between two categorical variables were examined using the chi-square test. Multivariate Cox proportional hazards model were used to assess association between LVI, chemotherapy and RS on overall survival (OS), while adjusting age, race, tumor size, grade, LN status, median income, and education level. The estimated HR for each variable in the model, along with its 95% CI, was reported. All tests are two-sided with significance level ≤5%. All analyses were conducted using SAS 9.4.

Results: 77,425 women met inclusion criteria, 65,018 N0 and 12,407 node-positive (N+). 2870 deaths were seen. LVI was present in 12.7% of cases, and associated with poor tumor grade, high RS ≥26, and N+ (all p&lt;0.0001), but not black race. Black race was associated with with larger tumor size, poorer tumor grade, high RS ≥26, and N+ (all p&lt;0.0001). Tumor-related factors associated with poorer OS included LVI (p&lt;0.0001), larger tumor size (21-50 vs 0-20 mm, p&lt;0.0001), higher RS (11-25 vs 0-10, p=0.039, ≥26 vs 0-10, p&lt;0.0001), poor histologic grade (3 vs 1, p&lt;0.0001) and N+ (p&lt;0.0001). Demographic factors associated with worse OS were older age (p&lt;0.0001) and black race (p&lt;0.0001). Median income was inversely associated with OS (p&lt;0.0001). LVI correlated with poor grade and higher RS, and with N+ (p&lt;0.0001). LVI was associated with worse OS in the entire cohort [HR 1.241 (95% CI 1.120, 1.375, p&lt;0.0001)] and in N0 patients [HR 1.355 (95% CI 1.195, 1.536, p&lt;0.0001)], but not in N+. LVI was associated with worse OS in N0 patients with RS 11-25 [HR 1.292 (95% CI 1.074, 1.555)] and ≥26 [HR 1.553 (95% CI 1.277, 1.888)], but not in patients with RS 0-10. Test for interaction between RS and LVI was not significant.

Conclusion: LVI adds prognostic information in ER+, HER2-, N0 BCA with RS 11-100. Black race is associated with worse OS, and with adverse prognostic factors such as high grade and high RS, but not with LVI.

Citation Format: Della Makower, Juan Lin, Xiaonan Xue, Joseph A Sparano. Lymphovascular invasion (LVI), the 21-gene recurrence score, and race in early estrogen receptor-positive, HER2-negative breast cancer: A national cancer database (NCDB) analysis [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-06.

Phase I Trial of Triapine-Cisplatin-Paclitaxel Chemotherapy for Advanced Stage or Metastatic Solid Tumor Cancers

Ribonucleotide reductase (RNR) is an enzyme involved in the de novo synthesis of deoxyribonucleotides, which are critical for DNA replication and DNA repair. Triapine is a small-molecule RNR inhibitor. A phase I trial studied the safety of triapine in combination with cisplatin–paclitaxel in patients with advanced stage or metastatic solid tumor cancers in an effort to capitalize on disrupted DNA damage repair. A total of 13 patients with various previously treated cancers were given a 96-h continuous intravenous (i.v.) infusion of triapine (40–120 mg/m²) on day 1, and then 3-h i.v. paclitaxel (80 mg/m²) followed by 1-h i.v. cisplatin (50–75 mg/m²) on day 3. This combination regimen was repeated every 21 days. The maximum tolerated dose (MTD) for each agent was identified to be triapine (80 mg/m²), cisplatin (50 mg/m²), and paclitaxel (80 mg/m²). Common grade 3 or 4 toxicities included reversible anemia, leukopenia, thrombocytopenia, or electrolyte abnormalities. The combination regimen of triapine–cisplatin–paclitaxel resulted in no objective responses; however, five (83%) of six patients treated at the MTD had stable disease between 1 and 8 months duration. This phase I study showed that the combination regimen of triapine–cisplatin–paclitaxel was safe and provides a rational basis for a follow-up phase II trial to evaluate efficacy and progression-free survival in women with metastatic or recurrent uterine cervix cancer.

Abstract P4-21-37: Phase I trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer

Background

Preclinical and clinical studies suggest that trastuzumab resistance in HER2 amplified breast cancer (HER2+ BC) is mediated by cross-activation of alternative signaling pathways. Computational analysis and pooled whole-genome RNAi screens in HER2 transformed BC cell lines identified the IL6/JAK2/STAT3 axis as a master regulator pathway. The combination of trastuzumab plus ruxolitinib, a JAK1/JAK2 inhibitor, demonstrated synergistic tumor growth inhibition in mouse xenografts of HER2 transformed BC cell lines. These data provide the rationale for studying the efficacy of ruxolitinib and trastuzumab in a clinical trial.

Design

This is a multi-center, open-label, phase I/II trial of ruxolitinib plus trastuzumab in patients (pts) with HER2+ metastatic BC (MBC) who have progressed on &gt;2 HER2-directed therapies in the metastatic setting (including trastuzumab, pertuzumab and T-DM1). The phase I is an adaptive design with 10 pts, using the time-to-event continual reassessment method to determine the recommended phase II dose. Phase II will be a non-randomized, open-label trial with 30 evaluable pts. The duration of a treatment cycle is 21 days, with trastuzumab given on Day 1 and ruxolitinib taken orally twice daily continuously. The primary endpoint of phase I is to determine the maximum tolerated dose of the drug combination. The phase I dose range for ruxolitinib is 10-25 mg BID (dose level 0: 20 mg BID). Response is assessed by imaging every 9 weeks. Blood samples and optional tissue biopsies are obtained for biomarker analysis at the following time points: pre-treatment, on-treatment C2D1, and at progression.

Results

Phase I started accrual in the fall of 2014. The trial has accrued 12 patients, with 9 evaluable and 3 non-evaluable patients. Of the evaluable patients, the mean age was 55.9 (range 32-69). Of these, 7 were postmenopausal (78%) 5/9 (56%) were estrogen receptor positive, and all had measurable disease. The mean number of prior lines of therapy in the metastatic setting was 5.6 (range: 3-8), including a mean of 3.2 (range: 2-5) prior regimens containing HER2 targeted therapies. As of 6/12/16, 2 patients remain on therapy. As this is an adaptive design, efficacy and drug tolerability will not be mentioned in this abstract to not bias the ongoing analysis. However, we anticipate that by SABCS 2016, 10 evaluable patients will have completed the DLT period – at which point, complete data will be presented.

Conclusion

Ruxolitinib plus trastuzumab is a novel, non-chemotherapy containing regimen. The phase I analysis is ongoing. We plan on reporting full safety/tolerability and efficacy data once 10 evaluable patients have completed the phase I (9/10 have currently completed DLT period). Given an early signal in HER2+ breast cancer, in this heavily pretreated population we will proceed directly to a phase II trial with the combination.

Citation Format: Mundi PS, Lee S, Chi D, Bhardwaj A, Makower D, Cigler T, Crew KD, Hershman DL, Califano A, Silva J, Kalinsky KM. Phase I trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-37.

Abstract P6-12-08: Phase I study of low dose oral cyclophosphamide (C) plus the poly-ADP-ribose- polymerase (PARP) inhibitor veliparib (V) in women with HER2/neu-negative inoperable locally advanced/metastatic breast cancer (MBC): NCI P8853

BACKGROUND: PARP, an essential nuclear enzyme, is involved in the recognition of DNA damage and facilitation of DNA base-excision repair (BER). PARP inhibition sensitizes tumor cells to cytotoxic agents which induce DNA damage, including C. Metronomic dosing of C may optimize potential for synergy with PARP inhibitors, and also inhibits angiogenesis (Kerbel et al, Nat Rev Cancer, 4:423-36, 2004) and may enhance anti-tumor immunity (Ghiringhelli et al. Cancer Immunol Immunother 56:641–648, 2007) V is an oral small molecule inhibitor of PARP which potentiates the antineoplastic activity of DNA damaging agents such as C in MX-1 breast xenograft model (Donawho et al Clin Cancer Res 13:2728-37, 2007). We performed a phase I trial of metronomic dose oral C plus V in patients with MBC.

METHODS: The primary objective was to determine the safety and identify the recommended phase II dose (RPTD) of the combination of low-dose oral C once daily in combination with V (100, 200, 300 mg) administered BID for 21 days using a standard 3+3 design. Eligibility included HER2/neu negative MBC, ECOG PS 0-1, and at least 1 prior chemotherapy regimen for MBC. Dose limiting toxicity (DLT) was defined as any Grade 3 non-hematological toxicity or Grade 4 thrombocytopenia/neutropenia occurring during cycle 1. After the RPTD of V was shown to be 200 mg BID with C 50 mg daily, the trial was amended to increase the C dose to 75, 100 and then 125 mg daily until hematologic toxicity was dose-limiting.

RESULTS: 31 patients were enrolled, 19 treated with 50 mg of C and 12 treated at higher doses (75-125 mg), with V doses ranging from 50 mg-300 mg BID (see table);5 patients with not evaluable due to rapid disease progression (N=2), non-compliance (N=2), or tumor pain that was not a DLT (N=1). Median age was 52 years (28-72 years), 14 (45 %) had triple negative disease, all had at least 1 prior chemotherapy regimen for metastasis (median 2, range 1-8), and, 7 had germline BRCA mutations, (3 BRCA1 and 4 BRCA2). When combined with 50 mg C daily, RPTD of V was 200 mg PO BID, with nausea being DLT at 300 mg BID. DLT was not observed in any of the 9 additional patients. The median number of cycles given was 3 (range 1-14). Clinical benefit (response or stable disease for at least 24 weeks) occurred in 3/7 (43%), 1/3 (33%) and 1/16(6%) for BRCA mutated, BRCA negative and BRCA unknown, respectively. Median progression-free survival was 4.3 months (1.2-10.9 months) for BRCA mutated patients and 2 months (0.7-10 months) for non-mutated.

CONCLUSIONS: The combination of oral continuous dosing of V (200 mg PO BID) with metronomic C (50, 75, 100 and 125 mg daily) is well tolerated and shows antitumor activity in patients with BRCA mutation associated MBC. The RPTD is C 125 mg daily plus V 200 mg BID, although further escalation of the C dose may be feasible since DLT was not seen at this dose level.

Dose LevelsDose Level# Patients/Evaluable# DLTType of DLTDL 1 :V 50mg , C 50mg3/30 DL 2 :V 100 mg, C 50mg4/30 DL 3 :V 200 mg, C 50mg6/61HeadacheDL 4 :V 300 mg, C 50mg6/52Nausea (N=2)DL 3A :V 200 mg; C 75mg3/30 DL 3B :V 200 mg, C 100mg6/30 DL 3C :V 200 mg, C 125mg3/30 

Citation Format: Anampa JD, Patel M, Pellegrino C, Fehn K, Makower D, Oh S-y, Noah K, Chen A, Sparano JA, Andreopoulou E. Phase I study of low dose oral cyclophosphamide (C) plus the poly-ADP-ribose- polymerase (PARP) inhibitor veliparib (V) in women with HER2/neu-negative inoperable locally advanced/metastatic breast cancer (MBC): NCI P8853 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-12-08.

Abstract OT3-01-06: Phase I/II trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer

Background:

Integrated analysis of whole genome RNAi screening with computationally reverse engineered interactome models identified IL6/JAK/STAT as a master regulator pathway essential for growth of ErbB2/HER2 positive breast cancer. Ruxolitinib (R), FDA-approved treatment for myelofibrosis, inhibits JAK1 and JAK2. The combination of R plus Trastuzumab (T) is synergistic in tumor growth inhibition in mouse xenografts of HER2 amplified breast cancer cell lines. These data provide a strong rationale for studying the efficacy of combination R and T in a clinical trial.

Trial Design:

A multi-center, open-label, phase I/II (P1/2) trial of R plus T in HER2+ metastatic breast cancer (MBC) who have progressed on T-based therapy. P1 will be an adaptive design with 10 patients, using the time-to-event continual reassessment method. The recommended P2 dose (RP2D) will be used in a non-randomized, open-label P2 trial with 30 evaluable patients (pts). Given the anticipated limited overlapping toxicities, approximately 36 pts (range: 32-40) are expected for the P1/2. The duration of a treatment cycle will be 21 days. R will be taken orally twice a day continuously. The P1 dosing range will be 10-25 mg BID (dose level 0: 20 mg BID). T will be administered on Day 1 of each cycle at standard dosing. Objective Response Rate (ORR) will be assessed by imaging every 9 weeks. Blood samples will be obtained for biomarker analysis, pre-treatment, on-treatment on C2D1, and then at progression. Pre-treatment biopsies from archival tissue or new biopsy, on treatment biopsy on C2D1, and upon progression of disease will be discussed with pts with accessible disease.

Main Eligibility Criteria:

1. HER2 positive MBC

2. Progression on HER2-directed therapy in metastatic setting, including Pertuzumab and T-DM1

3. Measurable or non-measurable disease

4. LVEF great than 50%

5. No history of prior JAK2 inhibitor

6. No HIV-positive or active infection

7. No concurrent medications that are potent CYP3A4 inhibitor or inducer

Specific Aims:

1. Primary: P1: MTD of combined R + T. P2: Progression Free Survival (PFS)

2. Secondary: a) Clinical: ORR, clinical benefit rate (CBR), and tolerability. Pts will be stratified by hormone receptor (HR) status to explore differences in efficacy between HR+ and HR-.

b) Explore potential predictive tumor and blood-based predictive biomarkers at baseline, on treatment, and progression: (tumor: pSTAT3 expression); serum: IL-6, IL-8, C-reactive protein; circulating tumor cell pSTAT3 expression; and tumor gene expression.

Statistical Methods:

Assuming a historical PFS of 8 weeks with single-agent agent HER2-targeted therapy in HER2+ MBC after progressing on T-based therapy, we predict that pts receiving the combination of R plus T will have a PFS of at least 13 weeks. With a 2-sided alpha of 0.05, we have 80% power to detect a difference with 30 pts.

Target Accrual:

Sample Size: 32-40 pts; projected over 2 years at 4 sites: Columbia, Einstein, Mount Sinai, and Cornell. Trial accruing since Fall 2014.

Citation Format: Kalinsky K, Chi D-C, Lee S, Bhardwaj A, Makower D, Cigler T, Crew KD, Hershman DL, Califano A, Silva J, Maurer M. Phase I/II trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-06.

Progress in adjuvant chemotherapy for breast cancer: an overview

Breast cancer is the most common cause of cancer and cancer death worldwide. Although most patients present with localized breast cancer and may be rendered disease-free with local therapy, distant recurrence is common and is the primary cause of death from the disease. Adjuvant systemic therapies are effective in reducing the risk of distant and local recurrence, including endocrine therapy, anti-HER2 therapy, and chemotherapy, even in patients at low risk of recurrence. The widespread use of adjuvant systemic therapy has contributed to reduced breast cancer mortality rates. Adjuvant cytotoxic chemotherapy regimens have evolved from single alkylating agents to polychemotherapy regimens incorporating anthracyclines and/or taxanes. This review summarizes key milestones in the evolution of adjuvant systemic therapy in general, and adjuvant chemotherapy in particular. Although adjuvant treatments are routinely guided by predictive factors for endocrine therapy (hormone receptor expression) and anti-HER2 therapy (HER2 overexpression), predicting benefit from chemotherapy has been more challenging. Randomized studies are now in progress utilizing multiparameter gene expression assays that may more accurately select patients most likely to benefit from adjuvant chemotherapy.

Abstract OT1-1-09: Phase I/II trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer

Background

Integrated analysis of whole genome RNAi screening with computationally reverse engineered interactome models identified IL6/JAK/STAT as a master regulator pathway essential for growth of ErbB2/HER2 positive breast cancer. Ruxolitinib (R), FDA-approved treatment for myelofibrosis, inhibits JAK1 and JAK2. The combination of R plus Trastuzumab (T) is synergistic in tumor growth inhibition in mouse xenografts of HER2 amplified breast cancer cell lines. These data provide a strong rationale for studying the efficacy of combination R and T in a clinical trial.

Trial Design

A multi-center, open-label, phase I/II (P1/2) trial of R plus T in HER2+ metastatic breast cancer (MBC) who have progressed on T-based therapy. P1 will be an adaptive design with 10 patients, using the time-to-event continual reassessment method. The recommended P2 dose (RP2D) will be used in a non-randomized, open-label P2 trial with 30 evaluable patients (pts). Given the anticipated limited overlapping toxicities, approximately 36 pts (range: 32-40) are expected for the P1/2. The duration of a treatment cycle will be 21 days. R will be taken orally twice a day continuously. The P1 dosing range will be 10-25 mg BID (dose level 0: 20 mg BID). T will be administered on Day 1 of each cycle at standard dosing. Objective Response Rate (ORR) will be assessed by imaging every 9 weeks. Blood samples will be obtained for biomarker analysis, pre-treatment, on-treatment on C2D1, and then at progression. Pre-treatment biopsies from archival tissue or new biopsy, on treatment biopsy on C2D1, and upon progression of disease will be discussed with pts with accessible disease.

Main Eligibility Criteria:

1. HER2 positive MBC

2. Progression on &gt;2 HER2-directed therapy in metastatic setting, including Pertuzumab and T-DM1

3. Measurable or non-measurable disease

4. LVEF &gt;50%.

5. No history of prior JAK2 inhibitor

6. No HIV-positive or active infection

7. No concurrent medications that are potent CYP3A4 inhibitor or inducer

Specific Aims

1. Primary: P1: MTD of combined R + T. P2: Progression Free Survival (PFS)

2. Secondary: a) Clinical: ORR, clinical benefit rate (CBR), and tolerability. Pts will be stratified by hormone receptor (HR) status to explore differences in efficacy between HR+ and HR-.

b) Explore potential predictive tumor and blood-based predictive biomarkers at baseline, on treatment, and progression: (tumor: pSTAT3 expression); serum: IL-6, IL-8, C-reactive protein; circulating tumor cell pSTAT3 expression; and tumor gene expression.

Statistical Methods

Assuming a historical PFS of 8 weeks with single-agent agent HER2-targeted therapy in HER2+ MBC after progressing on T-based therapy, we predict that pts receiving the combination of R plus T will have a PFS of at least 13 weeks. With a 2-sided alpha of 0.05, we have 80% power to detect a difference with 30 pts.

Target Accrual

Sample Size: 32-40 pts; projected over 2 years at 4 sites: Columbia, Einstein, Mount Sinai, and Cornell. Trial will start accruing July 2014.

Citation Format: Kevin Kalinsky, Dow-Chung Chi, Shing Lee, Amy Tiersten, Della Makower, Ellen Chuang, Katherine D Crew, Dawn L Hershman, Jose Silva, Andrea Califano, Matthew Maurer. Phase I/II trial of ruxolitinib in combination with trastuzumab in metastatic HER2 positive breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT1-1-09.

A phase I-II study of the histone deacetylase inhibitor vorinostat plus sequential weekly paclitaxel and doxorubicin-cyclophosphamide in locally advanced breast cancer

Histone deacetylases (HDACs) are a family of enzymes that regulate chromatin remodeling and gene transcription. Vorinostat is a panHDAC inhibitor that sensitizes breast cancer cells to taxanes and trastuzumab by suppressing HDAC6 and Hsp90 client proteins. Fifty-five patients with clinical stage IIA-IIIC breast cancer received 12 weekly doses of paclitaxel (80 mg/m(2)) plus vorinostat (200-300 mg PO BID) on days 1-3 of each paclitaxel dose plus trastuzumab (for Her2/neu positive disease only), followed by doxorubicin/cyclophosphamide (60/600 mg/m(2) every 2 weeks plus pegfilgrastim). The primary study endpoint was pathologic complete response (pCR). pCR occurred in 13 of 24 evaluable patients with Her2-positive disease (54, 95 % confidence intervals [CI] 35-72 %), which met the prespecified study endpoint. pCR occurred in 4 of 15 patients with triple negative disease (27, 95 % CI 11-52 %) and none of 12 patients with ER-positive, Her2/neu negative disease (0, 95 % CI 0-24 %), which did not meet the prespecified endpoint. ER-positive tumors exhibited lower Ki67 and higher Hsp70 expression, and HDAC6, Hsp70, p21, and p27 expression were not predictive of response. Vorinostat increased acetylation of Hsp90 and alpha tubulin, and reduced expression of Hsp90 client proteins and HDAC6 in the primary tumor. Combination of vorinostat with weekly paclitaxel plus trastuzumab followed by doxorubicin-cyclophosphamide is associated with a high pCR rate in locally advanced Her2/neu positive breast cancer. Consistent with cell line and xenograft data, vorinostat increased acetylation of Hsp90 and alpha tubulin, and decreased Hsp90 client protein and HDAC6 expression in human breast cancers in vivo.

Taxane chemotherapy treatment for metastatic breast cancer

SUMMARY The taxanes, paclitaxel, docetaxel and nab-paclitaxel, are among the most active cytotoxic agents for treatment of breast cancer. Significant progress has been made in addressing taxane dose and schedule in both early-stage and metastatic disease. Several studies have clarified the role of retreatment with taxanes in recurrent breast cancer patients previously treated with taxane-containing regimens. In addition, the advent of nab-paclitaxel, designed to reduce allergic reactions and enhance drug delivery to tumor cells, has provided additional therapeutic options. This article summarizes the uses of taxanes in the treatment of metastatic breast cancer.

How do I treat inflammatory breast cancer?

Inflammatory breast cancer (IBC) is an uncommon and aggressive presentation of locally advanced breast cancer that is potentially curable when localized but may be associated with distant metastasis in up to one-third of patients at presentation. The diagnosis of IBC is made based on clinical features, including the presence of skin edema and erythema involving at least one-third of the breast, with or without a mass, and usually associated with dermal lymphatic invasion (DLI) on skin biopsy. Management requires combined modality therapy, including neoadjuvant chemotherapy with an anthracycline and taxane-based regimen, followed by surgery and radiotherapy, plus concurrent anti-HER2 therapy for HER2-positive disease, and endocrine therapy for at least 5 years after surgery for estrogen-receptor-positive disease (Fig. 1). There have been few large clinical trials focused on IBC; therefore, most data regarding treatment are derived from retrospective analyses, small studies, and extrapolation of results from trials of noninflammatory locally advanced breast cancer. Patients with IBC should be encouraged to enroll in clinical trials whenever possible. In addition, further research into the biology of IBC may help to elucidate the mechanisms underlying its aggressive clinical behavior and to assist in the development of therapies targeted for this specific population.

Phase I and pharmacokinetic study of the ribonucleotide reductase inhibitor, 3-aminopyridine-2-carboxaldehyde thiosemicarbazone, administered by 96-hour intravenous continuous infusion

PURPOSE

3-aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP; Triapine; Vion Pharmaceuticals Inc, New Haven, CT) is a potent inhibitor of ribonucleotide reductase, with activity in preclinical tumor model systems. A phase I trial was initiated to determine the dose-limiting toxicities, maximum-tolerated dose, and pharmacokinetics of a 96-hour intravenous (IV) continuous infusion in patients with advanced cancer.

PATIENTS AND METHODS

Initially, courses were administered every 3 weeks, using an accelerated titration design. Subsequently, courses were administered every 2 weeks, and the dose was escalated in cohorts of three to six patients.

RESULTS

Twenty-one patients were enrolled, seven on the every-3-week schedule and 14 on the every-other-week schedule. Three of six patients at 160 mg/m(2)/d developed dose-limiting toxicities including neutropenia, hyperbilirubinemia, and nausea or vomiting. Based on these initial results, the dose for 3-AP was re-escalated beginning at 80 mg/m(2)/d but administered every 2 weeks. At 120 mg/m(2)/d, three of seven patients had dose-limiting but reversible asthenia, hyperbilirubinemia, and azotemia or acidosis; however, in the case of renal and hepatic adverse events, the events were related to pre-existing borderline abnormal organ function. Therefore, the recommended phase II dose for 3-AP administered by 96-hour IV infusion is 120 mg/m(2)/d every 2 weeks. Detailed pharmacokinetic studies demonstrated linear kinetics up to 160 mg/m(2), with substantial inter-patient variability. There was no correlation between dose and clearance (R(2) = 0.0137). There were no objective responses, but there was prolonged stabilization of disease or decreases in serum tumor markers associated with stable disease in four patients.

CONCLUSION

The 96-hour infusion of 3-AP is safe and well tolerated at the recommended phase II doses. Phase II trials of Triapine are ongoing.

A pilot study of edrecolomab (Panorex, 17-1A antibody) and capecitabine in patients with advanced or metastatic adenocarcinoma

Edrecolomab (Panorex) is a monoclonal antibody directed against the 17-1A antigen located on the cell surfaces of carcinomas. Clinical activity has been seen in colon and breast cancer. This trial investigated the feasibility of combining edrecolomab with the oral fluoropyrimidine capecitabine (Xeloda). Patients received a loading dose of edrecolomab 500 mg intravenously (i.v.) on day--14, followed 2 weeks later by 100 mg i.v. every 28 days (day 1). Capecitabine was administered to single-patient cohorts at escalating doses of 1500, 2000, and 2500 mg/m2/day in two equally divided doses for 14 of 21 days, beginning on day 1. Additional patients were enrolled at the 2500 mg/m2/day dose level to better define the toxicities of combination therapy. Toxicity assessment was the primary endpoint. Twenty seven patients with advanced or metastatic adenocarcinoma were enrolled on this study: 20 were evaluable for toxicity and 18 for response. The most common toxicities were elevated liver enzymes, diarrhea, and hand-foot syndrome. In cycle 1, grade 3 hand-foot syndrome was seen in two patients, and grade 3 diarrhea in one patient. Grade 2 toxicities included diarrhea, hand-foot syndrome, anemia, leukopenia, and transaminitis. Cumulative hand-foot syndrome was observed in four patients treated beyond two cycles. Three patients had edrecolomab infusion reactions during the course of treatment. One complete response and two partial responses were seen. Nine patients had disease stabilization lasting a median of 17.5 weeks (range 14.5-28+). Edrecolomab and capecitabine may be safely given in combination to patients with advanced or metastatic adenocarcinoma. Clinical activity is seen in this heavily pretreated patient population.

Phase II clinical trial of intralesional administration of the oncolytic adenovirus ONYX-015 in patients with hepatobiliary tumors with correlative p53 studies

PURPOSE

ONYX-015 is a genetically modified adenovirus with a deletion of the E1B early gene and is therefore designed to replicate preferentially in p53-mutated cells. A Phase II trial of intralesional ONYX-015 was conducted in patients with hepatobiliary tumors to determine the safety and efficacy of such a treatment.

EXPERIMENTAL DESIGN

All patients had biopsy-proven, measurable tumors of the liver, gall bladder, or bile ducts that were beyond the scope of surgical resection. Patients received intralesional injections of ONYX-015 at either 6 x 10(9) or 1 x 10(10) plaque-forming units/lesion up to a total dose of 3 x 10(10) plaque-forming units, and i.p. injections were allowed in patients with malignant ascites. The status of p53 was assessed by immunohistochemistry or Affymetrix GeneChip microarray analysis. Studies were conducted for viral shedding and for the presence of antiadenoviral antibodies before and after the injection of ONYX-015. Patients were assessed for response and toxicity.

RESULTS

Twenty patients were enrolled, and 19 patients were eligible. Half of the patients had primary bile duct carcinomas. Serious toxicities (> grade 2) were uncommon and included hepatic toxicity (three patients), anemia (one patient), infection (one patient), and cardiac toxicity (one patient, atrial fibrillation). Sixteen patients were evaluable for response. Among these evaluable patients, 1 of 16 (6.3%) had a partial response, 1 of 16 (6.3%) had prolonged disease stabilization (49 weeks), and 8 of 16 (50%) had a >50% reduction in tumor markers. Of the 19 eligible patients, 18 (94.7%) had specimens available for p53 analysis. Fifteen of these 18 patients (83.3%) had evidence of p53 mutation by one or both methods, although the methods correlated poorly. Viral shedding was confined to bile (two of two patients) and ascites (four of four patients). Pretreatment adenoviral antibodies were present in 14 of 14 patients and increased by 33.2% after ONYX-015 treatment.

CONCLUSIONS

Intralesional treatment with ONYX-015 in patients with hepatobiliary tumors is safe and well tolerated, and some patients had evidence of an anticancer effect. The high incidence of p53 mutations in these tumors makes this a logical population in which to test this therapy but precludes definitive evaluation about the necessity of a p53 mutation for ONYX-015 clinical activity.

Persistent replication of the modified chimeric adenovirus ONYX-015 in both tumor and stromal cells from a patient with gall bladder carcinoma implants

PURPOSE

ONYX-015 is a chimeric, E1B-deleted adenovirus designed to replicate preferentially in p53-deficient tumor cells; however, little is understood about its actual replication potential in human tumors. We hypothesized that replication of a late viral gene, hexon, would demonstrate replication of virus in human tissues.

EXPERIMENTAL DESIGN

In the course of a clinical trial, a patient with paired abdominal wall implants from a primary gall bladder carcinoma was injected with ONYX-015, 1 x 10(10) viral particles/lesion, followed by sequential excision of the lesions at 37 h and 7 days. Tissue sections were analyzed for evidence of viral replication.

RESULTS

In situ Reverse transcription-PCR was used to measure expression of hexon. Strong signals were obtained in gland-forming tumor cells both at 37 h and at 7 days. Signal was predominantly observed in the cytoplasm. The signal was also observed in adjacent normal stromal cells. Analysis of p53 status of the tumor by immunohistochemistry and Affymetrix Genechip demonstrated an inactivating mutation in p53. Routine H&E staining of the tumor sections revealed no evidence of necrosis at 37 h or 7 days after injection of virus. Presence of viral protein at both 37 h and 7 days was confirmed by immunohistochemistry using antibodies directed against hexon, penton, and fiber proteins.

CONCLUSIONS

Evidence for replication of hexon confirms that ONYX-015 is not only present but capable of replicating in tumor cells up to 1 week after intralesional injection and that replication is not confined to p53-mutated tumor cells.

Phase I clinical trial of irinotecan with oral capecitabine in patients with gastrointestinal and other solid malignancies

The purpose of this study was to determine the safety of irinotecan and capecitabine in patients with advanced solid tumors. Thirty-four patients received 122 courses of irinotecan 200 to 300 mg/m(2) as an intravenous infusion during 30 minutes on day 1 and capecitabine 1,500 to 3,000 mg/d orally 12 hours apart starting on day 2 for 14 days, repeated every 21 days (one course). Three to seven patients were treated in six dose-escalation cohorts. Three of 7 (43%) patients treated with irinotecan 300 mg/m(2) and capecitabine 2,300 mg/d had course 1 dose-limiting toxicity (DLT) defining maximum tolerated dosage (MTD). Fatigue and diarrhea were the major DLTs, and other events included neutropenia, anorexia, and hand-foot syndrome. At one dose level below the MTD, none of 7 patients treated with irinotecan 275 mg/m(2), and capecitabine 2,300 mg/d (36 courses) had course 1 DLT. Grade III to IV toxicities beyond course 1 included neutropenia (11% of all courses), fatigue (3.4%) and hand-foot syndrome (3.4%). There were only two episodes of febrile grade II neutropenia. There were no toxic deaths. Transient antitumor response was noted in one patient with irinotecan and 5-fluorouracil-refractory colon cancer. The combination of irinotecan 275 mg/m(2) and capecitabine 2,300 mg/d represents a safe, favorable, and convenient outpatient regimen warranting further phase II evaluation.

Fallopian tube carcinoma presenting with a brain metastasis

BACKGROUND

Fallopian tube carcinoma is a rare gynecologic cancer. An extensive literature search reveals no previous case report of fallopian tube carcinoma presenting with a brain metastasis.

CASE

A 63-year-old woman presented with 3 weeks of progressive left-sided weakness. CT scan of the brain revealed a solitary lesion in the right parietal lobe. The patient underwent a complete resection, followed by whole-brain radiation therapy. Pathologic review demonstrated adenocarcinoma with follicular structures. A directed workup revealed a large right adnexal mass. She underwent resection of a large fallopian tube carcinoma with normal ovaries. She recovered from surgery and is receiving combination chemotherapy.

CONCLUSION

This is the first case report of a fallopian tube carcinoma presenting as a brain metastasis.

Hodgkin's disease involving the large bowel

Hodgkin's disease (HD) is a malignancy that rarely affects the gastrointestinal tract. We describe a patient with disseminated, relapsed HD, in whom HD was found in a colorectal polyp. We also review the literature regarding HD involving the colon. To our knowledge, this is the first reported case of colonic HD presenting as a polyp.

Interferons as biomodulators of fluoropyrimidines in the treatment of colorectal cancer

Interferons (IFN)-alpha, -beta, and -gamma enhance the activity of 5-fluorouracil (5-FU) in vitro and in vivo. Various mechanisms have been identified to account for this modulation. First, IFN induces the enzyme thymidine phosphorylase, thereby enhancing the conversion of 5-FU to its active metabolite, 5-fluorodeoxyuridine monophosphate (FdUMP), leading to increased depletion of thymidine triphosphate pools and increased DNA fragmentation. Second, IFN treatment leads to abrogation of an 5-FU-associated increase in the enzyme thymidylate synthase (TS), thus increasing tumor sensitivity to 5-FU. Finally, IFN augments plasma 5-FU levels. Single-institution studies of 5-FU in combination with IFN-alpha showed high response rates; however, randomized trials demonstrated equivalent survival to 5-FU alone or in combination with leucovorin (LV). Randomized trials of 5-FU double-modulated by both IFN-alpha and LV showed no response or survival advantage compared with 5-FU/LV, and greater toxicity. The randomized trials are all limited by inconsistent schedules of administration of IFN-alpha. The combination of 5-FU and IFN-beta has shown promising results in single-arm and small randomized trials. A large randomized trial, requiring a standardized schedule of administration of IFN-beta, has been initiated.

Therapeutic efficacy of theophylline in chronic lymphocytic leukemia

Theophylline, a methylxanthine commonly used as a treatment for asthma, has been shown to induce apoptosis in chronic lymphocytic leukemia (CLL) cells both in vitro and in vivo. We have treated three advanced CLL patients with theophylline, and seen responses in two. The clinical courses of the responders are presented, and the literature concerning theophylline as therapy for CLL is reviewed.

Familial hairy cell leukemia

Familial hairy cell leukemia (HCL) occurs rarely, and HCL occurring in association with other hematologic malignancies is even rarer. We describe two cases of familial HCL syndromes: a mother and son with HCL, and a HCL patient whose aunt developed Hodgkin's Disease (HD). This is the first reported familial association of HCL with HD.

Interferon induces thymidine phosphorylase/platelet-derived endothelial cell growth factor expression in vivo

The enzyme/cytokine thymidine phosphorylase/platelet-derived endothelial cell growth factor (TP/PD-ECGF) has diverse functions within cells, including the regulation of steady-state thymidine levels, the conversion of the cancer chemotherapeutic agent 5-fluorouracil (FUra) to an active metabolite, and the mediation of angiogenesis in normal and malignant cells. Although the levels of TP/PD-ECGF vary substantially among different tissues and are generally found to be elevated in tumors, little is known about the control of its expression in vivo in humans. In this study, peripheral blood mononuclear cells were obtained from patients prior to and during treatment with IFN and FUra and analyzed for TP/PD-ECGF expression. Sixteen of 21 patients (76%) exhibited an average 3-4-fold increase of TP/PD-ECGF protein levels after treatment with either IFN-alpha or-beta, with the remaining patients having either a decrease (four patients) or no change (one patient) at the sampling times examined. Expression in vivo increased rapidly within 1-2 h of IFN treatment and remained elevated for up to 48 h after its administration. The increase in TP/PD-ECGF protein was accompanied by a concomitant increase in TP/PD-ECGF mRNA levels. TP/PD-ECGF mRNA expression in cells in vitro was induced by IFN but not by pharmacologically relevant concentrations of FUra, suggesting that the IFN was responsible for the induction seen in the patients. This study demonstrates that IFN induces TP/PD-ECGF expression in vivo by regulation of the level of mRNA expression.

Occurrence of myeloma in a chronic lymphocytic leukemia patients after response to differentiation therapy with interleukin-4

The occurrence of chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) in a single individual is rare, and the clonal relationship between the two neoplasms is unclear. We describe here a patient with CLL who developed symptoms of MM while responding to experimental therapy with interleukin-4 (IL-4). This patient was treated with 2-chlorodeoxyadenosine (2-CDA), and had a response in both malignancies.

Thymidine phosphorylase mediates the sensitivity of human colon carcinoma cells to 5-fluorouracil

Interferon-alpha (IFN alpha) potentiates the antitumor activity of 5-fluorouracil (FUra) in colon cancer in vitro, in vivo, and clinically. A likely mechanism for this action is the induction by IFN alpha of thymidine phosphorylase (TP), the first enzyme in one pathway for the metabolic activation of FUra to fluorodeoxyribonucleotides. To test this hypothesis, an expression vector containing the TP cDNA was transfected into HT-29 human colon carcinoma cells. Five stable transfectants were selected and analyzed. All showed increased sensitivity to FUra cytotoxicity, ranging from a 2-fold to a 19-fold decrease in the IC50 for FUra, compared to wild-type cells. Levels of TP mRNA, protein, and enzyme activity were elevated in the transfectants, and there was a significant correlation between the relative increase in sensitivity to FUra and both the increase in both TP mRNA levels and TP activity. Transfected cells exhibited increased formation of FdUMP, but not the ribonucleotides FUDP and FUTP, from FUra when compared to wild-type cells. The changes in TP activity, FdUMP formation, and FUra sensitivity in the transfected cells were comparable with those seen after treatment of wild-type cells with IFN alpha. These studies provide direct evidence for the role of TP in mediating the sensitivity of colon carcinoma cells to FUra, and further support the importance of the induction of TP in the biomodulating action of IFN alpha on FUra chemosensitivity.